October 2015




Ethics of femtosecond laser-assisted cataract surgery

by Ellen Stodola EyeWorld Staff Writer


Its important as surgeons to distinguish what the surgeon personally believes might be true and what is actually proven to be true. Kendall Donaldson, MD


Experts delved into the topic at a session at the 2015 ASCRS•ASOA Symposium & Congress

In a session at the 2015 ASCRS•ASOA Symposium & Congress co-sponsored by the ASCRS Cataract Clinical Committee and Ophthalmology Business, experts discussed the ethics of femtosecond laser-assisted cataract surgery. Richard Hoffman, MD, Eugene, Ore., served as moderator of the panel, which featured John Banja, PhD, Atlanta, Kendall Donaldson, MD, Miami, Donald Serafano, MD, Long Beach, Calif., Michael Snyder, MD, Cincinnati, and Abhay Vasavada, MD, Ahmedabad, India.

The session started with audience response questions, which asked those in attendance if they are currently using femtosecond cataract surgery and whether they believe there are ethical dilemmas related to the surgery. About 42% indicated that they are not using the femtosecond laser but are interested, while 33% said they do use it, and 22% indicated that they have no intention of using it at this time. About half of the audience believed that there are modest associated ethical dilemmas that are easy to overcome. The panel then discussed a number of scenarios and gave their opinions on how to proceed.

The first scenario was a question of access, with a patient coming to a practice on the recommendation of a friend who had successful cataract surgery done by the surgeon. The surgeon does not perform femtosecond laser cataract surgery and does not have access to a laser, but the patient is requesting femtosecond laser cataract surgery. Audience responses on this question were split between referring the patient to an ophthalmologist with access to a laser and discussing the attributes and limitations of the laser and talking the patient out of laser cataract surgery.

Dr. Snyder believes the solution to the ethical dilemma would be very dependent on whether the surgeon thinks its a superior technology or not. There is a translational problem, not only with femto but with multifocal/toric lenses, he said, because some surgeons have positive feelings and some have negative feelings about these technologies. When we try to talk our patients into (or out of) things, there is an ethical question and theres also the tremendous obligation that comes with that, he said.

Dr. Donaldson said its important as surgeons to distinguish what the surgeon personally believes might be true and what is actually proven to be true.

An important detail for patients undergoing surgery with the femtosecond laser to know is how experienced their surgeon is. The experts discussed telling the patient about the value of the femtosecond laser but also informing the patient if you have done a limited number of these procedures. Tell the patient that you are a novice with the femtosecond laser and offer multiple options to move forward. You always have to be honest, Dr. Serafano said. Thats a given. Another topic that came up was what to do if the patient is not a candidate but is requesting the use of the femtosecond laser for surgery. Dr. Donaldson suggested telling patients if they dont fit into a category for use, even if the surgeon thinks the technology is better.

Moving to another topic, Dr. Banja and Dr. Snyder stressed the importance of not making assumptions about what a patient can afford. Dr. Banja tells healthcare providers that they should be careful about making assumptions about a patients ability to pay. Dr. Snyder agreed and said he has had patients tell him that they cant afford certain premium treatments only to find out that they likely could have. People choose how they wish to allocate their funds, and they choose how they wish to present themselves at the office, he said.

In one example, a 92-year-old woman said she cant afford a premium IOL or the additional costs of the femtosecond laser, but the surgeon performing the surgery has a laser and believes that it would be advantageous in her case. Dr. Banja said that healthcare providers do not have an obligation to provide free care.

The experts debated questions such as: If the femtosecond laser is better, how much better is it than manual? If it is a superior technology, wouldnt this mean that everyone should be using it? How much better would it need to be over manual surgery before it becomes unethical to not use it for all patients? Some ophthalmologists are concerned that if they go entirely to femto, they will lose their manual skills, Dr. Banja said. There is also a possibility that the laser could have mechanical problems that would impact its effectiveness. Dr. Serafano described a case where he experienced an error with the laser and it wouldnt work. For his patients scheduled for that day, he had to offer them the option of rescheduling or proceeding with a conventional procedure. Its all about the patients, he said. My financial interest is my problem, not theirs. This means that it has to be very clear to surgeons that if there is a problem and the laser cant be used, they need to be prepared to proceed in the best interest of the patient.

Editors note: Dr. Banja has no related financial interests. Dr. Donaldson has financial interests with Alcon (Fort Worth, Texas) and Abbott Medical Optics (Abbott Park, Ill.). Dr. Hoffman has financial interests with Carl Zeiss Meditec (Jena, Germany). Dr. Snyder has financial interests with Alcon, Haag-Streit (Koniz, Switzerland), and HumanOptics (Erlangen, Germany). Drs. Serafano and Vasavada have financial interests with Alcon.

Contact information

Banja: jbanja@emory.edu
Donaldson: KDonaldson@med.miami.edu
Hoffman: rshoffman@finemd.com
Serafano: serafano@verizon.net
Snyder: Msnyder@cincinnatieye.com
Vasavada: icirc@abhayvasavada.com

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